 Now, once again, reminding that we have various quizzes which are happening around. So in the exhibition areas, we have quizzes which you have to fail using Google Forms. So, Sandrad, we have another set of the questions today. We'll take the question and answers and discuss them as well. And today, we'll have five questions at the Vivier Imaging stall. So please visit these areas in the exhibition stalls and please do participate. So after this, we'll have a short change in the schedule. Dr. Malini Lavande Ma'am will take her talk on MRI anatomy of elbow and wrist first. And Dr. Amit Chaudhary will take his talk on DTI anatomy later around 12 o'clock. So let's start with the quiz. This is not a prize-winning quiz, but definitely we'll revise few important cases. And this will be a poll-based quiz. So we'll have our poll options on starting with the quiz. These are all neuro questions. So there'll be 15 neuro questions. And let's start with the first one here on your screen. MRI finding depicted on this image may be seen with all except. So the question is all except. So I saw most of you chose option A, but later on you saw that word all except. So extra pontine myelinolysis, flavivirus, encephalitis, vernicase of Wilson's. So this is something very easy. We all revise it often. T2, basal ganglia, symmetric hyperintensity and their differentials. So 37% have said C and then again there is a divide. So let's see what the answer is. It's C. So it can be seen with extra pontine myelinolysis, flavivirus, encephalitis and Wilson's, but this kind of appearance of T2 hyperintensity in basal ganglia is not common with vernicase encephalopathy. So this is a list of differential of T2 hyperintensity in basal ganglia. Ischemia, hypoxic ischemic encephalopathy, venous infarction we already saw. Autoimmune encephalitis, CJD, extra pontine myelinolysis, toxins like carbon monoxide, cyanide neurotoxicity. Almost any kind of viral encephalitis can lead to this picture and even lymphoma can cause it. But what do we see in vernicate? We see it as T2 flare hyperintensities which are symmetrical, but they are in the areas of mammillary body, which we saw today in the anatomy talk. Dorsomedial thalamide, tectal plate, periequeductal grimatter around the third ventricle. So now this is the second question on your screen. And you can see the images, sagittal T2, post contrast T1 and axial. And these are your options on the screen. What is your possible diagnosis of this patient who is a 47-year-old male and has complaints of acute onset, upper limb tingling and numbness? So there are polling options on your screen. Right, so we have received a lot of responses. And let's see what it is. So it is 42% of you feel it is hemangioblastoma and 13% as thinking of B, 16 for tuberculomas also. So what is this? It's a 47-year-old male gentleman. And the diagnosis for this case is hemangioblastoma. So what we saw here was a lesion, which is relatively hypo intense on T2-weighted images and a lot of perilesional edema. And it's a nodular enhancement, which we have seen that what we are not identifying is that there is no obvious large cystic component, no obvious hemorrhagic area. And anything which will be there in this spinal cord will always cause a lot of edema or disproportionate edema because of the fact that spinal cord is a small area, is a constricted space. So spinal hemangioblastomas are the third most common intra medullary spinal neoplasm representing 2 to 6% of all intra medullary tumors. So they should be thought as a differential whenever fits into and their age group is 40 to 50 years of age. Mostly you see like discrete nodules. Sometime there will be syringes or cysts associated with them and the most common location is the thoracic cord. Great. Now this is another differential question on your screen and the options are also there. So we can start the poll. MRI findings depicted on this image can be seen with all except. So there is a finding. These are diffusion and axial flare images and you have to identify what all can cause it. But the answer has to be the one which cannot cause this particular finding. Yeah. So we have received the responses but a lot of confusion in there. So but 29% think that it is the option D which is methanol toxicity. So let's see what this entity is and what is the answer. The answer to this question is methanol toxicity and this is called as the cytotoxic lesion of the corpus callosum. Also called as the transient spleenial hyper intensity. And we have a lot of causes for this like seizures can also that's just a post-tictal thing. So it is most of the time confused with infarct. Restricted diffusion may make you think that it's a small infarct. But the location and flare hyper intensity and clinical correlation makes it easier. So it can be post epilepsy or post seizure. Metabolic disturbances like electrolyte imbalance, infections, CNS malignancies. Drugs and toxins can also lead to this. Even subarachnoid hemorrhage sometime can cause this to happen. But methanol toxicity will not cause this finding commonly here. That time we see bilateral basal ganglia changes. So now let's move to the next question and this is the question with options on your screen. There are sagittal T2 and T1 weighted images and you have to identify what this condition is. So we can have the polling options. So 36% of you think that this is metastasis. And then 37% have diagnosed it as cumulus. So in all these questions, we are seeing a lot of divide like almost 20, 20% of what's are going to each of the options. So I hope that the three days which we have the neuro MSK and body imaging MRI days will definitely help us all clear these doubts. So this was cumulus. So this is an entity where we have the osteonecrosis of the bone. And you have delayed vertebral body collapse due to ischemia and non-union of the anterior vertebral bodies with which fractures after major trauma. These are not metastasis where you can see that even the margins, the posterior margins are not convex. There is wedging of these vertebrae. They are not homogenously hyper intense on T1 weighted images. And on T2, you can also see this positive fluid sign, which is seen with osteoporotic fractures. So these are all osteoporotic fractures or traumatic fractures. And they have developed into bone infarcts or osteonecrosis. Next question is on your screen and with four options. So we can start the poll at the same time. 57 year old gentlemen with progressive bilateral fission of palsy. And all of them are the possible diagnosis except. So we have the result and the maximum 47% votes are to the option number D, which is scleroderma. And that is the correct answer. So what we are seeing here on this image is that there are multiple cranial nerves which are involved and they are thickened and they are enhancing. So we are dealing with a situation where we have multiple cranial nerve involvement, thickening enhancement. And the differential to this is metastasis neurofibromatosis type 2. Lymphoma is an important one. Leukemia, multiple sclerosis, CIDP. Limes is not very common in India. Neurosarquoid and metachromatic leukodystrophy. So commonly seen are lymphoma, neurosarquoid and maybe with metastasis and also with perineoplastic syndromes. But scleroderma will not cause any CNS symptoms. So that was the answer. Next question on your screen. This is a young male patient, 29-year-old. And he has complaints of headache and vomiting. And these are the images on your screen. This was there in the Sennrad quiz yesterday. Those of you who have participated, so you can see the images. And I'll take the slide to the option one. Also this one is the slide with options. This colorful image which you are seeing is the perfusion ASF. Non-contrast perfusion which we can perform and assess the areas of hyperperfusion within this lesion. This is post-contrast T1, pre-contrast T1. So most of you have identified it correctly as a typical central neuropsychoma. So this is a typical central neuropsychoma and because of the location, because of the morphology, you can identify it correctly. So these are WHO grade 2 neuroepithelial intraventricular tumors with fairly characteristic imaging features. And they usually have heterogeneous appearance and heterogeneous post-contrast enhancement. Calcification is common and can be typically puncted. MR spectroscopy where we saw a tall choline peak also is a characteristic feature. Another set of images on your screen. Next question. So here you see a post-contrast axial T1 diffusion and coronal T2. You see a lesion which is homogenously enhancing restricted diffusion and T2 hypo intensity. This is the same patient where we have obtained a single voxel spectroscopy. Yesterday we had a good talk in detail about the spectroscopy. So this is how this patient spectroscopy looked like and these are your four options. All are true for this pathology except lipid peak is seen due to active presence of macrophages containing a strong rate of moving lipid. CT hypo dense enhancing supratentorial mass. Choline peak may be seen. Restricted diffusion is a characteristic. So again, I'll show you the image. This is the finding and these are the options. So we have the answers with us and 34% of you feel that this is answer number C. 32% are towards answer option number B. So what is it? Choline peak may be seen and CT hypo dense enhancing supratentorial mass. So first of all, we should diagnose what this situation is. This is primary CNS lymphoma, a lesion which is homogenously enhancing. Lesion which is showing restricted diffusion and is showing a tall choline peak. So this is your creatinine at 3.02. So this peak is your choline at 3.22. And you can see that the choline peak is above the creatinine peak which should not be there. So this is the reversal of your hunter's angle. So you definitely see elevated choline. So what are all these features suggestive of these are suggestive of hypercellularity. So you have something which is hypercellular densely packed cells are there and that fits into lymphoma. So anything which will be densely cellular and which will be kind of densely packed cells will be present. Then that has to look hyper dense on CT, not hypodense. Therefore, this option is correct. This option is the answer of the question. So you will see everything except the CT hypo dense lesion. That was the question. In primary CNS lymphomas, you can have typical hypo intense T1 lesions which are showing restricted diffusion and MR spectroscopy will show you choline peak and along with the choline peak because of these macrophages, you will also have a lipid-lactate doublet peak. So that is the twin peak sign which is seen with lymphoma. So this is the next question on your screen. These are MRI images depicting acute and subsequent chronic changes in pediatric DC spectrum. So the question is not asking you the diagnosis. This was also there in the Sunrat quiz yesterday. So these are three images of the same disease in acute phase and these are the two in the same DC spectrum, different patient in later phase, chronic phase. So in this particular disease, the calvaryal size changes. Whatever the diagnosis is, the calvaryal size changes. So you have to choose one option where the size of the calvarium does not change similar to the change in this disease. So little tricky question, but you can attempt it easily. All of you can vote. We are, these are all anonymized responses. So all of you can participate. So the responses wise, the answer to the question you have given is C glutamic acid urea type one, which is the diagnosis in this situation. So that was your correct. But the answer as per the question asked is D fetal rubella syndrome. So what is it? This is glutamic acid urea type one. So yesterday it was in Sunrat quiz and those of you have answered this as glutamic acid urea have scored one plus in this quiz question. So you see that there is an area of restricted diffusion and T2 hyperintensity with edema in bilateral basal ganglia. And later on you can see that the sylvan fishers are widened out. And these areas are smaller in size and basal ganglia T2 hyperintense. So this is glutamic acid urea type one. What happens to the calvarium here? You get macrocephaly. So the size increases. So everything which can increase this skull size of macrocephaly related pathologies are congenital hydrocephalus, hydrancephaly, neurofibromatosis type one, tuberous sclerosis, metabolic storage disorders, Alexander's canavans, glutamic acid urea, noonans. But rubella which is a part of your taut spectrum, tauts infestation lead to microcephaly and not macrocephaly. So therefore that was the answer. Now this is your next question. The ninth question on your screen. This is also one taken from yesterday's Sunrat quiz. You can choose your answers from the option box. So most of you feel that it is the second option, medulloblastoma. And that is the correct answer. The appearance is little odd. So there was some confusion, but this is medulloblastoma, which is the most common malignant brain tumor of the childhood. And we'll have the details of all these tumors on 15th of August when we have the neuro day for the MRI course. And just to revise, we have four types. That is your WNT, sonic hedgehog and group three and group four. So the ones which are in midlines, they can be group three, group four. Cerebellar hemisphere involvement is very likely with the sonic hedgehog variety. And therefore that has intermediate prognosis. Whereas the cerebellar peduncles when involved with the WNT subgroup that has the best prognosis. Next question on your screen. So we can have the polling options. So here is a young person who has developed progressive soft swelling over the left frontal convexity and the person is immunocompetent. So what is your diagnosis? Metastasis, osteosarcoma, aspergilloma or lymphoma. So we have the answers and most of you feel it is aspergilloma, 41% and then 27% feel it is osteosarcoma. So we have a CT image also where you see that there is complete bone erosion. So even we got the diagnosis correct after the histopathology and microbiology came in. So this is a case of aspergilloma where retrospectively we saw that this mass lesion was completely more or less hypo intense on T2 weighted images and flare images and also that there was complete osteosarcoma on swan. They were areas of blooming which could correspond to the fungal hyphae and fungal byproducts. So aspergilloma can have various radiographic presentations and they may be associated fungal ball or masses which can be slow growing and they will cause osteosarcoma like this. They can also cause involvement of the vessels, vasculitis and cerebral infarction. Next question on your screen, you have to identify the phenomena. So you have your polling options. So most of you have identified this phenomena correctly. So this is cross cerebellar diastasis. So this is something interesting. We had this in last year's quiz also and you see this on ASL non-contrast perfusion image. There is a phenomena where one part of your cerebral hemisphere is hypoperfused and contralateral cerebellar hemisphere is hypoperfused. So this refers to depression in function, metabolism and perfusion affecting the cerebellar hemisphere occurring as a result of the contralateral focal supratentorial abnormality. So this patient had a focus status epilepticus episode and this is a post-tectal change. So most likely the phenomena is due to interruption of the corticopontoserebellar white matter tract. So we have few more questions left and then we can move ahead to the next talk which is on MRI anatomy of elbow and wrist. This is the question on your screen, identify the lesion. These are very commonly seen in the brain but in the cord sometime it's rare. So your polling options are on your screen and you see sagittal T2 and sagittal T1 post-contrast and axial post-contrast. So 50% of you think these are intra medullary tuberculomas and that is the correct answer. So still 50% had some doubt related to this particular thing. So these are typical T2 hypo intense lesions which are peripherally enhancing and we see lot of perillational edema conglomerate lesions. Final intra medullary tuberculomas are rare and most of the time secondary to the tubercular involvement elsewhere in the body. So this patient also had multiple tuberculomas in the brain and also they were pulmonary involvement. So this is the next case fetal MRI and you can start polling. If you have commented that will this be available as a part of recording, yes you will get the quizzes also and so you can review these images again in those recorded sessions and to this most of you have replied as A venous gallon and then see Dural sinus malformation. So this is a fetal MRI with a large abnormal flow void which is a vascular channel but the location is not venous gallon. So we have just seen the venous anatomy and revised it. So we know that venous gallon malformation is somewhere here. So this is a Dural sinus malformation which has been partially thrombosed and they are known to resolve also. So in fetal MRI if you pick it up or even on fetal ultrasound if you pick it up if you follow them they will slowly reduce in size. So that is important to identify. Sometime if they are thrombose on ultrasound people may think that these are posterior fousa masses. So this is not venous gallon malformation. Another question you have this phenomena of transynaptic degeneration. Which tract is involved in this particular phenomena? So you have two sets of images and we are showing two abnormalities which are interrelated. So we have our polling answers and we see that 43% of you feel it is dentator rubro olivary pathway and next 38% is cerebellum olivary pathway. So this is something related to the olivary pathway. So this is hypertrophic olivary degeneration which is happening because of this cavernoma and the pathway which is involved here is the dentator rubro olivary pathway which is resulting in hypertrophy of the inferior olivary nucleus. So the parts are red nucleus, inferior olivary nucleus and the contralateral denti nucleus. This is something interesting. Last question for this quiz and then we can go to the next topic for the day. Identify the pathology. So we can start with the polling options. So we have already received over 100 responses and most of you feel that it is option number 2, scintillincephaly which is the correct answer. So what is this scintillincephaly? So this is a spectrum in the entity of holoprosincephaly and you will see middle inter hemispheric variant which is a mild subtype of holoprosincephaly that is characterized by an abnormal midline connection of the cerebral hemisphere between the posterior frontal and the parietal region. So this is something which is very similar to lobar holoprosincephaly but the inter hemispheric fissure is characteristically absent. The rest of the brain appears more or less normal structurally and here you have appearance of a mono ventricle due to fusion. So this is scintillincephaly. So thank you everyone with this we come to an end of this short quiz which was mainly for neuro cases and now it's time to move to our next talk. There are more quizzes and there are quizzes in the exhibition area so please do participate. Yesterday's winner we are going to announce tonight and today's quiz will continue.